Program Fails to Spur More Use of Generic Cancer Drugs

Kerry Dooley Young

May 07, 2019

A voluntary program intended to encourage use of generic cancer medicines failed to produce expected results, perhaps because participants in the initiative already were inclined to use the less costly treatments.

The program is described in a study published in Health Affairs, authored by Laura Yasaitis, PhD, and Atul Gupta, PhD, from the University of Pennsylvania in Philadelphia, and colleagues.  

Between 2007 and 2016, when practices were negotiating new contracts with the private insurance firm UnitedHealthcare, the company offered a program of increased reimbursement for a dozen widely used generic drugs.

The generic drugs included in this program were 5-fluorouracil, cisplatin, docetaxel, doxorubicin, gemcitabine, irinotecan, oxaliplatin, topotecan, vinorelbine, paclitaxel, etoposide, and carboplatin.

No details are provided on the specifics of this increase for generic drugs, but the authors note in their study that reimbursement for these medicines in the program was equal to — or sometimes still lower than — what physicians received for prescribing brand-name medicines.

Over the course of the study, just over one third of eligible oncology practices (695 of 1905, 36%) switched to United's incentivized fee schedule, the authors note.

In analyzing the results, the authors found a statistically nonsignificant difference between the use of generic cancer drugs by physicians who participated in the UnitedHealthcare program and those who did not.

The probability of prescribing one of the generic cancer medicines decreased by 3.4% for patients treated by practices that participated in the program, compared with those that did not, and anticancer drug spending decreased by 2.3%.

The Health Affairs article also includes a table showing an overview broadly summarizing the characteristics of the two groups. Looking at the mean 30-day episode spending, the cost for anticancer drugs for the group of physicians who didn't participate in the incentivized program was $10,191, compared with $11,069 for physicians who participated in the program.

The authors note that consumers also had to pay for a significant part of the cost of their care.

"Even with full private insurance, UnitedHealthcare enrollees were responsible for almost $700, on average, in out-of-pocket spending during the first month after initiating anticancer drug treatment," they write.

The finding that this program to incentivize generic oncology drugs did not alter either treatment patterns or spending on care was rather surprising, and the authors discuss potential explanations for why this was the case.

The emergence of several new targeted anticancer drugs could have affected the results, they suggest.  "For some patients with specific mutations, evidence-based care could have mandated starting first-line therapy with one of these brand-name drugs," they write.

Another explanation is the fact that physicians who switched into the program were more likely to have prescribed at least one of the incentivized drugs before switching (92.2% vs 87.6%).

That is a difference that may have been critical in the outcome of the test, study authors Gupta and Justin Bekelman, MD, also with the University of Pennsylvania, told Medscape Medical News in an interview.

"Even before they joined the program, the providers who eventually joined were much more likely to prescribe these evidence-based generics," Gupta said. "There was less potential for that behavior change. They were already doing what United wanted them to do."

This is a common challenge for the field of studies focused on changing financial incentives to try to improve care and restrain cost growth, said Bekelman, who is director of the Penn Center for Cancer Care Innovation.

There is a robust interest in this kind of work, much of it driven by the federal Center for Medicare and Medicaid Innovation (CMMI). Somewhat akin to a venture fund for tests meant to improve medical care while restraining costs, CMMI has largely funded voluntary programs. It suffered a defeat with a bid to compel participation in a test known as the Comprehensive Care for Joint Replacement (CJR).

Many medical groups opposed the plan and complained to Congress. In November 2017, the Centers for Medicare & Medicaid Services finalized the cancellation of a mandatory hip fracture bundled payment model that CMMI had sought in the CJR program.

Overall, the results from voluntary CMMI projects have thus far been mixed, with the center reporting to Congress in April that some of its "model tests have not shown reduced expenditures."

In Bekelman's view, the Health Affairs article "clearly [highlights] the main challenge of voluntary programs."

"They attract practices or providers that are likely to succeed," he said. "But it is often in other providers where we are looking to inspire practice transformation toward higher-value healthcare."

This research presented was funded by the American Cancer Society and the National Cancer Institute. UnitedHealthcare provided data sets for the study, which researchers at the University of Pennsylvania analyzed. One author, Era Kim, is an employee of UnitedHealthcare. Another author, Lee Newcomer, is a former employee of UnitedHealthcare.

Health Aff. Published online May 2019. Abstract

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